Alerts

Changes to IRHC Billing Effective October 1, 2017

Some important changes are coming that impact how IRHCs file claims to Medicaid for payment. Please carefully read the following information and share with all appropriate staff who are involved with your Medicaid billing, as well as any vendor or clearinghouse you use for claims submission.

Effective October 1, 2017 Medicaid will eliminate the billing of a small range of services for the encounter rate. Currently, IRHCs are paid an encounter rate, by billing 99211-SE and 99231-SE, or the appropriate EPSDT screening codes. Effective October 1, 2017, instead of billing a limited range of codes, IRHCs will bill the actual procedure code for the services performed. This means IRHCs will refer to the Current Procedure Terminology (CPT) code book and bill the most appropriate code to reflect the services provided. Appropriate medical documentation must be present in the patient’s chart to support the level of care billed. When the claim is received for processing, DXC will add the T1015 procedure code to the claim and you will be reimbursed the encounter rate for services.

Services payable outside of the encounter rate will not be affected by this change, and will continue to be paid outside the encounter rate, under the non RHC NPI. These services include Vaccines for Children, deliveries, surgeries with place of service 21 or 22, lab, technical component for Electrocardiograms (EKGs) and radiology, and smoking cessation products (under family planning). Do not submit services outside of the encounter rate on the same claim as services within the encounter or the claim will deny. Because such services are paid separately they must be billed separately from the services that are part of the encounter. IRHCs should not mix the two types of services on claims – those that are part of the encounter and those outside of the encounter.

If you have any questions, please contact the Provider Assistance Center at 1-800-688-7989.